BREAST

Self Breast Examination (SBE)

1. What is the preferred imaging modality for a 29 yr
patient with a palpable breast mass?
a. Mammography
b. Ultrasound
c. CT scan
d. MRI

Answer : Ultrasound

Mammography – not ideal for women less than 30

years old because of breast density.

CT scan – generally not used for evaluation of breast

lesions.

MRI - false positive rate is 6% leading to unnecessary

mastectomy or additional biopsies.
Breast Cancer Screening and Diagnosis

Ultrasound
(preferred)

or

Lump/ mass Needle Sampling

Age <30 yr
or

Observe for 1- 2
menstrual cycles
(option for low clinical
suspicion)
2. What is the preferred imaging modality for a 49y/o
female patient with a palpable breast mass?
a. Mammography
b. Ultrasound
c. CT scan
d. MRI

Answer : Mammography

Mammography- can detect palpable and nonpalpable

masses including microcalcifications
in this age group.

Ultrasound- is not capable of detecting

microcalcifications
Breast Cancer Screening and Diagnosis

Final
Assessment
category 1- 3

Lump/ mass Mammogram

Age >30 yr

Final
Assessment
category 4- 5
3. A 28y/o female with a palpable breast mass had
an US result of a solid breast mass suspicious for
malignancy. What kind of biopsy is preferred in
this case?
a. FNAB
b. Core Bx
c. Incisional Bx
d. Excisional Bx

Answer : Core Bx

FNAB - sensitivity- 95%

- Needs an experienced cytopathologist
- False [+]- 0- 0.4% False [-] 0 – 4%
- Can not distinguish between in situ carcinoma and
invasive carcinoma accurately
Core needle bx - biopsy technique of choice specially
in the absence of an experienced
cytopathologist.
- sensitivity – 98.7%
- has the ability to distinguish
between in situ carcinoma and
invasive carcinoma.

Incisional bx - when open biopsy is indicated for

large lesions

Excisional bx - indicated when needle biopsy is

nondiagnostic and is discordant
with physical exam and imaging
findings.
- difficult to do BCS after this type of
biopsy.
 Breast Cancer Screening and Diagnosis
Core
needle
biopsy
(preferred)

Solid: Mammo- Tissue

or
Indeterminate gram biopsy
or suspicious

Excision
4. A 45y/o female underwent mammogram for
breast screening. Mammograms final assessment
was BIRADS Cat. 3. What would you do?
a. do nothing
b. do biopsy
c. surveillance/follow up

Answer : surveillance/follow up

BIRADS – Breast Imaging Reporting And Data

System
BIRADS Cat 3 – Probable benign findings-<2% risks
of malignancy
– Follow up – PE every 6 mos.,
mammogram every 6-12 mos. until
long term stability is demonstrated
(2 yrs or longer)
5. A 25y/o female underwent FNA for a breast mass.
Aspirate was non bloody fluid and the mass
completely disappeared . Next step would be:
a. cytology of aspirate
b. excision biopsy
c. follow up after 6 weeks

Answer : follow up after 6 weeks

Simple cyst are almost never malignant

Aspirated cyst fluid should not be routinely sent

for cytologic examination.
• The clinical validity of atypia identified in a cyst
aspirate fluid is questionable and of low yield.
• Hindle et.al. – routine cytologic exam of cyst
aspirate fluid often results in unnecessary
surgical biopsy and is not cost effective.
6. A 30y/o female underwent FNA for a breast mass.
Aspirated fluid was greenish brown in color. After
aspiration the mass did not completely resolve.
Next step would be:
a. cytology of aspirated fluid
b. excision biopsy
c. follow up after 6 weeks

Answer : excision biopsy

Indications for excision biopsy of a cyst after

FNA:
• bloody or serosanguineous aspirate
• residual mass
• recurrent cyst after 2 aspirations
 Breast Cyst - Algorithm
Breast mass

FNA Ultrasound

Cyst

Non-bloody Bloody Residual mass

Follow up after 6 wks. Excisional Bx Excisional Bx

Recur Does not recur

Reaspirate Follow up in 1 yr.

Recur

Excisional Bx
7. A 24y/o female consulted at your clinic because of
a breast mass of 2mos. duration. On PE mass was
found to be 2cms. in size, well circumscribed,
movable, and non tender. There were no palpable
axillary masses. Needle biopsy was done and
histopath result was fibroadenoma. Management
would be:
a. surgical excision
b. observe
c. total mastectomy
d. quadrantectomy

Answer : Surgical excision or observe

Surgical excision – if patient desires removal of the

mass
Breast mass can be observed if:
- characteristic (clinically benign) , 2 – 3cms. in
size
- < 25y/o, acceptable for those 25 – 30y/o but
probably not there after

Observation is at 3 – 6mos. interval for 1 – 2yrs.

FA usually cease to grow at 2 – 3cms and may

regress in postmenopausal women
8. A 45y/o female with a 5cms. breast mass
underwent core biopsy of said mass. Final
histopath showed malignant cystosarcoma
phylloides. Appropriate treatment would include:
a. wide excision
b. adjuvant chemotherapy
c. adjuvant hormonal therapy
d. MRM
e. adjuvant RT

Answer : wide excision

Wide excision with clear margins [ 1cms. ] –

appropriate surgical treatment of phyllodes tumors
whether benign or malignant.
Adjuvant chemotherapy- at present has no role for CSP
• role of chemotherapy [ Ifosfamide ] for metastatic
CSP currently under investigation.

Adjuvant hormonal therapy – no role in CSP

• ER & PR – [+] in 43% - 84% in epithelial
component
• [+] in 5% in stromal component

ALND – 20% with palpable axillary nodes

• <1% to 5% with [+] axillary nodes
• minimally invasive nodal sampling done for
clinically suspicious axillary nodes.

Adjuvant RT – role is unclear

• indicated in recurrent tumors after mastectomy
• anecdotal cases support the use of combined
chemo RT following CSP recurrences.
9. A 42y/o female with a 5cms. breast mass
underwent FNAB and was diagnosed to have
fibroadenoma. However, after excision, final
histopath turned out to be CSP. Further
management would be:
a. Immediate reexcision
b. Observe
c. RT to involved breast

Answer : Observe

Authors opinion differ on whether immediate

reexcision is necessary.
Chua, Thomas & Ng [ Singapore ] – 16%
recurrence rate
Zurrida et al [ Milan ] – 8% recurrence rate
These authors suggest that a “wait and watch” policy
for benign CSP may be considered in place of
mandatory surgical reexcision. Specially in cases
where reexcision would be difficult and deforming

10.A 35y/o female consulted because of breast pain

and tenderness. 3 days PTC, ultrasound was
done which showed a complex mass at the UIQ
of the left breast. Appropriate treatment would
be:
a. I&D + antibiotics
b. Repeated aspiration + antibiotics
c. Surgical excision
d. Core bx

Answer : Repeated aspiration + antibiotics

The combination of repeated aspiration and oral
antibiotics is usually effective at resolving local
abscess formation and is the current treatment of
choice for most breast abscesses. Aspiration should
be repeated every 2 – 3 days until no further puss is
obtained.

Immediate I&D is done if the skin overlying the

abscess in thinned and puss is visible on ultrasound.
11.Risk of subsequent breast CA among patients
with this benign breast lesion is not increased.
a. fibroadenoma
b. sclerosing adenosis
c. apocrine change
d. atypical ductal hyperplasia

Answer : apocrine change

Categorization of Benign Breast Lesions
according to the Criteria of Dupont,
Page, and Rogers
Nonprolifetative - NO Risk
Cyst
Papillary apocrine change
Epithelial-related calcifications
Mild hyperplasia of the usual type
Proliferative lesions w/o atypia - 1.5-2x Risk
Moderate or florid ductal hyperplasia of the usual type
Intraductal papilloma
Sclerosing adenosis
Fibroadenoma
Profilerative lesions w/ atypia - 4 -5x Risk
Atypical ductal hyperplasia
Atypical lobular hyperplasia
12.32 y/o female diagnosed with LCIS with negative
family history of breast or ovarian CA. Most
appropriate management would be:
a. Observation/ Surveillance
b. Chemoprevention with Tamoxifen
c. Prophylactic mastectomy
d. Breast conservation surgery

Answer : Observation and Surveillance

LCIS – 5% incidence
• marker of increased breast cancer risk but not
a disease by itself
• App. risk of developing invasive BCA is 1%/ yr.
• If with [ + ] family history risk is increased to
2% / yr.
Observation - strategy selected by most patients
 • 16.4% developed invasive BCA
• disease related mortality – 2.8% vs. 0.9%
(patients treated with prophylactic mastectomy).

Tamoxifen – reduce incidence of BCA by 49%

- effect not known in women <35y/o

Prophylactic mastectomy indications:

• New LCIS lesions – 16x risk
• Strong family history of breast and ovarian CA
• BRCA1 & BRCA2 genetic mutations
• Patient preference
13.A 39y/o female consulted with a mammogram
finding of suspicious calcifications on the right
breast. Core bx was done and histopath revealed
LCIS. However, not all calcifications were removed
during the core bx procedure. You would:
a. Observation / surveillance
b. Mammography guided needle localization bx
of remaining calcifications
c. Do RT of right breast

Answer : Mammography guided needle

localization bx of remaining
calcifications
LCIS is an incidental finding on biopsies. It does not
account for any physical findings or
mammographic/ ultrasonographic abnormalities.
Primary concern should focus on whether some
additional pathologic process is present that would
explain the clinical/ imaging feature that prompted
the biopsy. Although very low rates of significant
disease is found on follow up excision bx , the
preponderance of the data reveals that the
completely benign cases can not be reliably
predicted, and therefore follow up excision bx is the
definitive management
14.A 50y/o female consulted because of a
mammographic result of BIRADS-4. Needle
localization excision bx was done and histopath
result was DCIS 0.5cms. in size with negative
margins. Possible surgical management would
include:
a. Excision alone
b. Excision + RT
c. Total mastectomy
d. Total mastectomy + RT
e. MRM

Answers: Excision alone; Excision + RT;

Total mastectomy
 Adjuvant RT after total mastectomy is not indicated
in DC IS because total mastectomy alone has a local
recurrence rate of only about 1%.

Axillary dissection is not indicated in DCIS because

the incidence of ALN mets is only about 0.5%.

For many patients with DCIS total mastectomy is

over treatment.
Indications for Mastectomy:
• Large diffuse lesions [>3cms. in size]
• Documented multicentric disease
• Patient unwilling to take even the slightest
increased risk of death
• Patient with no interest for BCT or medically
unsuited for BCT
• Patient unwilling or unable to undergo careful
long term clinical follow up.
• Persistent [+] margins
 Ductal Carcinoma In Situ

Excision + RT
or
Total mastectomy
w/o lymph node
dissection +
reconstruction
Margins Excision + RT
negative or
Total mastectomy
Small (<0.5cm), w/o lymph node
unicentric, low dissection +
grade reconstruction or
Excision alone
15.A 52y/o female was diagnosed with DCIS. After
excision histopath result was; tumor size was
1.6cms., margins were >1cms., tumor was non-
high grade with comedo necrosis. Based on the
Van Nuys Prognostic Index, treatment of choice
would be:
a. Excision alone
b. Excision + RT
c. Total mastectomy

Answer: Excision + RT [VNPI score- 7]

Van Nuys Prognostic Index:

• Size score- 15mm or less- 1 ; 16mm to
40mm-2; 41mm or more- 3

• Margin score- 10mm or more- 1 ; 1mm to

9mm- 2 ; 1mm or less- 3
•Pathological Classification score- non-high grade w/o
comedo necrosis- 1 ; non- high grade w/ comedo
necrosis- 2 ; high grade lesion- 3

• Age score- >60y/o- 1 ; 40y/o to 60y/o- 2 ;<40y/o- 3

Treatment Recommendations:
Old New Recommendation
3 to 4 4 to 5 to 6 Excision alone
5 to 6 to 7 7 to 8 to 9 Excision + RT
8 to 9 10 to 11 to 12 Total mastectomy
16.A 45y/o patient consulted in your clinic because
of a 4cms. breast mass fixed to the pectoralis
muscles. There were palpable movable axillary
nodes in the ipsilateral axilla. Biopsy was done
and histopath result was IDCA. There were no
clinical evidence of metastases. What is the
clinical stage?
a. Stage III-B
b. Stage IV
c. Stage III-A
d. Stage II-B

Answer: Stage II-B [T2 N1]

T4a - Extension to chest wall , not including
pectoralis muscle

T2 - Tumor >2cms. but not >5cms. in greatest

dimension

N1- Metastasis to movable ipsilateral axillary lymph

node[s]

Stage II-B – T2 N1 M0
T3 N0 M0
17.A 57y/o patient has a 2cms. breast mass diagnosed
as IDCA. Nipple retraction and skin dimpling was
noted on the ipsilateral breast. There were no
palpable ipsilateral axillary nodes and there were no
clinical evidence of metastasis. What is the clinical
stage?
a. Stage IV
b. Stage III-C
c. Stage I
d. Stage III-B

Answer: Stage I [T1 N0]

T4b - Edema [including peau d’orange] or

ulceration of the skin of the breast, or
satellite nodules confined to the same breast.
T1c -tumor >1cm. but not >2cms. in greatest
dimension
 Skin of breast - Dimpling of the skin, nipple
retraction, or any other skin change
except those described under T4b
and T4d may occur in T1,T2,orT3
without changing the classification

18.A 61y/o patient has a 1.5cms. breast mass

diagnosed as IDCA. A palpable supraclavicular node
was also noted. What is the clinical stage?
a. Stage IV
b. Stage III-A
c. Stage III-B
d. Stage III-C

Answer: Stage III-C [T1 N3c M0]

N3a - Metastasis in ipsilateral infraclavicular lymph
node[s]

N3b - Metastasis in ipsilateral internal mammary

lymph node[s] and axillary lymph node[s]

N3c - Metastasis in ipsilateral supraclavicular lymph

node[s]
 Invasive Breast Cancer – PreOp Work up

• H&P
• CBC, platelets
• Liver function tests
• Chest x-ray
• Diagnostic billateral mammogram,
ultrasound as necessary
Stage I
• Pathology review
Stage IIA • Determination of tumor
Stage IIB estrogen/progesterone receptor (ER/PR)
T3, N1, M0 status and HER-2 status
• Breast MRI w/ dedicated breast coil may
be considered for breast conserving therapy
for preoperative evaluation of extent of
disease and detection of mammographically
occult disease in the breast (optional).
• Bone scan (optional)
• Abdominal CT or US or MRI (optional)
19.A 55y/o female consulted in your clinic because of
a 2cms. breast mass which was subsequently
diagnosed as IDCA. There were no palpable axillary
nodes. Possible surgical treatment would include:
a. Lumpectomy + ALND
b. Lumpectomy alone
c. Total mastectomy
d. MRM

Answer: Lumpectomy + ALND; MRM

BCS- Lumpectomy + ALND

BCT- Lumpectomy + ALND + RT
Incidence of [+] ALN mets in IDCA measuring 2cms.-
> 25%
20.A 62y/o patient with a 2.5cms. breast mass at
the UOQ of the right breast underwent bx which
showed IDCA. Mammography showed clustered
calcifications in the IUQ & LOQ of the right breast.
Bx of said lesions showed DCIS. Surgical treatment
of choice would be:
a. BCS
b. MRM
c. Radical mastectomy
d. Extended radical mastectomy

Answer: MRM
Absolute Contraindications to BCT:
• Women with 2 or more primary tumors in
separate quadrants of the breast or with diffuse,
malignant appearing microcalcifications are not
considered candidates for BCT.

• A history of previous therapeutic irradiation to

the breast region that, combined with the
proposed treatment, would result in an
excessively high total radiation dosage to a
significant volume.

• Pregnancy is an absolute contraindication to the

use of breast irradiation. However, in many
cases, it may be possible to perform BCS in the
3rd trimester and treat the patient with
irradiation after delivery.
 • Persistent [+] margins after reasonable surgical
attempts absolutely contraindicate BCT. The
importance of a single, focally [+] microscopic
margin needs further study and may not be an
absolute contraindication.

Relative Contraindications to BCT:

• A history of collagen vascular disease is a
relative contraindication to BCT, because
published reports indicate that such patients
poorly tolerate irradiation. Most radiation
oncologists will not treat patients with
scleroderma or active lupus erythematosus,
considering either an absolute contraindication.
In contrast, rheumatoid arthritis is neither a
relative nor an absolute contraindication.
• Patients with multiple gross tumors in the same
quadrant and indeterminate calcifications must be
carefully assessed for suitability because studies in
this area are not definitive.

• Tumor size is not an absolute contraindication to

BCT, although few reports have been published about
treating patients with tumors larger that 4 to 5cms.
However a relative contraindication is the presence of
a large tumor in a small breast, in which an adequate
resection would result in significant cosmetic
alteration. In this circumstance, preoperative
chemotherapy or endocrine therapy or the use of
partial breast reconstruction should be considered if
the patient desires BCT.
 • Breast size can be a relative contraindication.
Women with large or pendulous breasts can be
treated with irradiation if reproducibility of patient
setup can be ensured and if it is technically
possible to obtain adequate dose homogeneity

Non Mitigating Factors:

• The presence of clinical or pathologic
involvement in axillary nodes.Tumor location is
not a factor in the choice of treatment. Tumors
in a superficial subareolar location occasionally
may require resection of the nipple areolar
complex so that [-] margins can be achieved,
but this does not affect outcome. The patient
and her physicians need to assess whether such
a resection is preferable to mastectomy.
• A family history of BCA is not a contraindication
to BCT. In patients with a genetic BCA, it is
clear that the risk of ipsilateral breast tumor
recurrence is not increased. However, these
patients are at substantial risk of new primary
tumors in both the ipsilateral and contralateral
breast. This should be discussed during the
counseling process.

• A high risk of systemic relapse is not a

contraindication for BCT but it is a determinant
of the need for adjuvant therapy.
21.A 52y/o female underwent screening
mammography which showed microcalcifications
on her left breast. It was read as a BIRADS Cat 5
lesion. Management would include:
a. FNAB
b. Mammography guided needle localization
excision bx
c. Frozen section
d. If dx as malignant- determination of
hormone receptor status

Answer: Mammography guided needle

localization bx ; If dx as malignant-
determination of hormone receptor status

FNAB- difficult to do with microcalcifications

- can not differentiate between an in situ
and invasive lesion
Frozen section- generally not recommended

Frozen sections should not be performed on non

palpable lesions because of the loss of tissue caused
by the FS process. In addition, because most of the
specimen is fat [which does not freeze well], they are
technically difficult to perform, often inaccurate, and
may be extremely difficult to interpret. Most impt.,
definitive treatment should not be decided on until
permanent sections have been thoroughly evaluated.
With Tamoxifen W/o Tamoxifen

NSABP B14 -10 yr. rate of

recurrence in ipsilateral breast
4.3% 14.7%
Stockholm grp -3.0% -12.0%
W/ RT RT + Tamoxifen
NSABP B21 - 8 yr. rate of
ipsilateral recurrence 9.3% 2.8%
22.A 52y/o female who was diagnosed with IDCA is
undergoing MRM. During axillary dissection the
surgeon was able to palpate enlarged nodes
posterior to the pectoralis minor muscle.
Appropriate axillary dissection would be:
a. Axillary sampling
b. Level I dissection only
c. Level 1&2 dissection
d. Total axillary lymphadenectomy [level1,2,3]

Answer: Total axillary lymphadenectomy

Types of ALND:
• Axillary sampling- provides 4 to 7 nodes, includes
axillary tail of Spence and level 1 nodes
• Low level 1, dissection stops superiorly at the
level of the major intercostobrachial nerve

•Level 1, up to axillary vein superiorly; mean # of

nodes is 10; lateral border is the latissimus dorsi
and medial border is the pectoralis minor muscle

•Level 1&2, includes nodes posterior to the

pectoralis minor muscle and Rotter’s nodes.

• Level 1,2,3 [Total axillary lymphadenectomy]

medial border is the subclavius muscle[Halsteds
ligament]
Surgical Extent:
ALND is therapeutic by reducing the risk of
axillary recurrence to <5% and prognostic,
by allowing even more accurate
determination of nodal metastasis.

Clearly 80% - 90% of ALN are found in levels

1&2

A level 1&2 dissection is adequate in the

absence of gross disease.

Incidence of skip mets to level 3 - 1% to 3%

[+] level 1 nodes - 28% risk of mets to level 2&3
Skip mets to level 2- 1.2% - 5%
Level 1&2 [+]- 33% of level 3 nodes are [+]
 Incidence of lymphedema:
Axillary sampling 0 – 2.8%
Level 1&2 2.7% - 7.4%
Level 1,2,3 3.1% - 8%
Axillary RT 2.1% - 8.3%
Axillary RT + Total ALND 3 – 7 fold increase in incidence

Werner [MSKCC]
The level of node dissection was not statistically
related to the development of arm edema, the only
factor that was significantly associated was obesity.

Armando Giuliano [John Wayne Cancer Inst.]

When surgery is the treatment selected, level
1&2 dissection is sufficient for staging and local
control, with dissection of level 3 reserved for
extensive gross disease to improve local control.
23.A 55y/o female with a 4.5cms mass at the left
breast was diagnosed by core bx to have IDCA.
Patient underwent MRM. Margins were >1mm and
ALN were [-] for mets. Would you give adjuvant
RT?
a. Yes
b. No

Answer: No

Indications for PMRT:

• Patients with 4 or more [+] ALN
• Patients with 1 to 3 [+] ALN- there is
insufficient evidence to make recommendations
or suggestions for the routine use of PMRT in
these patients.
•Patients with T3 or Stage III tumors- PMRT is
suggested for patients with T3 tumors with [+] ALN
and patients with operable Stage III tumors

• Patients undergoing preop systemic therapy-

there is insufficient evidence to make
recommendations or suggestions on whether all
patients initially treated with preop systemic therapy
should be given PMRT following surgery.
 Invasive Breast Cancer – LocoRegional
Treatment of Clinical Stage I,II or T3,N1, M0
RT to chest wall +
supraclavicular
> 4 positive area(category1).
axillary nodes Consider RT to IMN
(category 3)
Total
mastectomy
w/ surgical Consider RT to chest wall +
axillary staging 1- 3 positive supraclavicular area
(category 1) + axillary nodes (category1) if RT is given,
reconstruction consider internal mammary
RT (category 3)

RT to chest wall. Consider

Negative axillary
RT to supraclavicular area
nodes and tumor
(category 2B) Consider RT
>5cm T3,No or
to internal mammary
margins positive
nodes (category 3).
 Invasive Breast Cancer – LocoRegional
Treatment of Clinical Stage I,II or T3,N1, M0

Negative axillary
nodes and tumor Consider RT to chest wall
<5cm and
Total margins close
mastectomy (<1mm)
w/ surgical
axillary staging Negative axillary
(category 1) + nodes and tumor
reconstruction <5cm and No RT
margins >1mm
24.A 70y/o female with a 9mm. right breast mass was
diagnosed b y core bx to have IDCA. Lumpectomy
+ ALND was done. Axilla was [-] for mets. Tumor
was ER+/PR+. Adjuvant treatment must include:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy

Answer: Adjuvant hormonal therapy

 Adjuvant RT should always accompany BCS.
However, in those 70 yrs. of age or older with ER+,
node[-], T1 tumors breast RT may be omitted.

There is no indication for chemotherapy in this

case. There is insufficient data to make
chemotherapy recommendation for those 70y/o and
over. Always consider comorbid recommendations.

Adjuvant hormonal therapy is indicated in all

patients with ER+/PR+ tumors.
25.A 50y/o female has an 8mm breast mass
diagnosed as IDCA. She underwent BCS. Axilla
had 2[+] nodes out of 10. Tumor was ER-/PR-.
Adjuvant treatment would include:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy

Answers: Adjuvant RT & Adjuvant

chemotherapy

For node [+] patients chemotherapy is given

regardless of age and hormone receptor status.
26.A 42y/o female with a 1.5cms. breast mass was
diagnosed to have IDCA. She underwent MRM.
Axillary nodes were [-] for mets. Tumor was ER-
/PR-. Adjuvant treatment would include:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy
d. No adjuvant therapy

Answer: Adjuvant chemotherapy

Invasive Breast Cancer – Systemic Adjuvant
Treatment – Hormone Non-Responsive
Disease

Histology pT1,pT2, or
ER- •Ductal, NOS pT3 and pN0
negative •Lobular or pN1mi (<
and PR- •Mixed 2mm
negative •Metaplastic axillary node
metastasis)
Invasive Breast Cancer – Systemic Adjuvant
Treatment – Hormone Non-Responsive
Disease

pN0 No adjuvant therapy

pT1,pT2, or Tumor<0.5cm
pT3 and pN0 or
or pN1mi (< Microinvasice Consider
pN1mi
2mm chemotherapy
axillary node
metastasis) Consider chemotherapy
Tumor 0.6-1.0cm
(category1)

Tumor >1cm Adjuvant chemotherapy

(category1)
27.A 39y/o female, premenopausal, with a 2cms. breast
mass was diagnosed with IDCA. BCT was done.
Tumor was ER+/PR+. What is the most appropriate
adjuvant hormonal treatment?
a. Ovarian ablation
b. Tamoxifen 20mgs. X 10yrs.
c. Tamoxifen 20mgs. X 5yrs.
d. Aromatase inhibitors
e. Megestrol acetate [Megace]

Answer: Tamoxifen 20mgs. X 5yrs.

Level II, grade A evidence supports no added

benefit of ovarian ablation in women with node
negative or node positive BCA who are treated with
chemotherapy. Whether there is benefit for women
who do not become amenorrheic following
chemotherapy is not known.
 Tamoxifen given for more than 5yrs. does not
improve LRR and DFS compared to Tamoxifen
given for a maximum of 5yrs.

Aromatase inhibitors at present are given only

to postmenopausal patients.

Megestrol acetate [Progerstin], is generally not

used because of the availability of better agents for
hormonal treatment.
28.A 46y/o premenopausal patient undergoes BCS
for a 2cms. tumor diagnosed as IDCA of the left
breast. The margins are clear and 5 out of 15 ALN
are [+] for mets. Tumor was ER-/PR+.
Recommended adjuvant treatment should be:
a. RT + Chemotherapy
b. RT + Hormonal therapy
c. Chemotherapy + Hormonal therapy
d. RT alone
e. Chemotherapy + RT + Hormonal therapy

Answer: Chemotherapy + RT + Hormonal

therapy

Chemotherapy- tumor size is >1cm.

RT- as part of BCT; >4 [+] ALN for mets
Hormonal Tx- tumor is PR+
29.What is the most appropriate sequence in giving
adjuvant therapy?
a. RT then Chemotherapy then Hormonal Tx
b. Hormonal Tx then Chemotherapy then RT
c. [RT + Chemotherapy] then Hormonal
d. Chemotherapy then RT then Hormonal Tx
e. Chemotherapy then Hormonal Tx then RT

Answer: Chemotherapy then RT then

Hormonal Tx

Chemotherapy is given initially because its

effect are both on locoregional and systemic
control.

RT is given next for locoregional control.

 Chemotherapy and RT are usually not combined
because of higher morbidity rates.

Hormonal treatment is given last and is given

for 5yrs. It is usually not combined with
chemotherapy or RT because theoretically it inhibits
cell proliferation.

Chemotherapy and RT is more effective on

proliferating cells.
American Society of Clinical Oncology For Breast
Cancer Follow-Up Care
Test Frequency
Recommended
Every 3-6 mo for 3 years;
History (eliciting of symptoms) and physical
every 6-12 mo for 2 years;
examination
then annually
Breast self-examination Monthly
Mammography Annually
Pelvic examination Annually
Patient educate regarding symptoms of
recurrence NA
Coordination of care NA
Not recommended
Complete blood cell count
Automated chemistry studies
Chest roentgenography
Bone scan
Ultrasound of the liver
Computed tomography of chest, abdomen,
and pelvis
Tumor marker CA-15-3
Tumor marker carcinoembryonic antigen
30.A 61y/o female consulted in your clinic because of a
7cms. ulcerating, fixed mass of the left breast.
There were palpable movable ALN in the left axilla.
Biopsy of the mass revealed IDCA. What would be
the appropriate initial management?
a. MRM
b. RT
c. Radical mastectomy
d. Extended radical mastectomy
e. Neoadjuvant chemotherapy

Answer: Neoadjuvant chemotherapy

 The historical experience of surgically treated
patients with LABC was poor. Although surgical
resection was technically possible, 10yrs. after
diagnosis >80% of patients had succumbed to the
disease.

After giving neoadjuvant chemotherapy a

major reduction in tumor volume occurred in most
[60% to 80%] patients. Clinical complete remissions
were reported in 10% to 20% of patients so treated
in most clinical trials. In one multicenter trial, the
increase in clinical and pathologic complete response
rate was associated with improved disease-free and
overall survival rates.
Invasive Breast Cancer –Treatment for LABC

MRM + RT Additional
or BCT or chemotherapy
Response
High dose + hormonal
RT alone therapy if
(category estrogen
Doxorubicin-or 3) receptor
epirubicin-based postive or
or paclitaxel-or unknown
docetaxel-based
preoperative
chemotherapy
preferred

Consider additional
No systematic
response chemotherapy and/or
preoperative radiation
31.A 62y/o female underwent BCT of the left breast
because of a 2cms. mass diagnosed as IDCA. 5yrs.
later, a 2.5cms. mass was noted again on the left
breast. Core bx was done and histopath result was
IDCA. What is the preferred surgical management?
a. MRM
b. BCS
c. Total mastectomy
d. Radical mastectomy

Answer: Total mastectomy

Management of LRBC after BCT:

Radiologic evaluation
• Bilateral mammography
• Other imaging studies as indicated [US and
MRI]
Establish diagnosis
• Core biopsy or surgical biopsy [preferred]
• FNA cytology

Metastatic workup for patients with invasive carcinoma

Treatment
• Mastectomy [preferred]
• Less than mastectomy [ local excision,
reirradiation] for highly selected patients

Consider systemic therapy [ chemotherapy

and/or hormonal therapy] for high risk patients [short
disease free interval, high grade tumor,[+] ALN].
32.A 49y/o patient underwent MRM for a 4cms. right
breast mass diagnosed as IDCA. There were no
nodes [+] for mets. 2yr. later, patient noted a
3cms. fixed mass on the chest wall. Biopsy of the
mass showed IDCA. Tumor was hormone receptor
[+]. Appropriate management would include:
a. Excision of chest wall mass
b. RT
c. Chemotherapy
d. Hormonal therapy
e. All of the above

Answer: All of the above

Management of LRBC after mastectomy:
• Establish diagnosis
• Metastatic work up
• Treatment
 Local excision if operable

 RT, generally to minimum volumes of chest

wall and supraclavicular fossa

 Consider chemotherapy and/or hormonal

therapy
 For inoperable local recurrence, consider

radiation [or reirradiation], systemic

therapy, other modalities [hyperthermia,
photodynamic therapy].
Invasive Breast Cancer –Treatment of LRBC

Surgical Consider
Initial treatment resection (if systematic
w/ mastectomy possible) + RT therapy
(if possible)

Local
recurrence
Initial treatment Consider
Mastectomy systematic
w/ lumpectomy
+ RT therapy
33.A 30y/o patient, pregnant AOG-10-11wks.,
consulted because of a 1.5cms. mass on the left
breast. Core bx result was IDCA. Appropriate
surgical treatment would be:
a. Lumpectomy + ALND
b. Lumpectomy alone
c. Total mastectomy
d. MRM

Answer: MRM

BCT is contraindicated in pregnancy specially

during the 1st and 2nd trimester.

ALND should always be a part of definitive

surgical procedures for the treatment of invasive
BCA.
34.Recommended adjuvant treatment for the above
case would be:
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy
d. None of the above
e. All of the above

Answer: None of the above

Management of PABC:
• MRM is the standard management of a patient
with BCA during pregnancy.
• RT should be avoided during any trimester
because of the dose, due mainly to internal
scatter, absorbed by the fetus.
• Chemotherapy during pregnancy must be
considered on a case by case basis because of
the risk of fetal damage, including the effort to
avoid chemotherapy in the 1st trimester. There is
an 11.5% to 12.7% incidence of teratogenicity
during the 1st trimester. Although chemotherapy
may be started during the 2nd trimester, there
are reports of impaired CNS development and
delayed cognitive damage during this period.

• Hormonal therapy is not indicated during

pregnancy because there is positive evidence of
human fetal risk [teratogenic or embryocidal
etc.].
35.A 50y/o woman consulted because of a 6cms.
mass at the right breast. Core biopsy showed
IDCA. Mammography was done which showed a
0.8cms. mass at the left breast. Biopsy result of
the left breast mass was DCIS. Both tumors were
hormone receptor [+]. Management would include:
a. MRM right, Lumpectomy left
b. Bilateral MRM
c. MRM right, Lumpectomy + ALND left
d. Adjuvant RT both sides
e. Adjuvant chemotherapy + hormonal therapy

Answer: MRM right, Lumpectomy left;

Adjuvant RT both sides; Adjuvant
chemotherapy + Adjuvant hormonal
therapy
Manage each lesion individually.

ALND is not necessary for DCIS lesions

Adjuvant RT is indicated for lesions 5cms. or more in

size and as part of management for DCIS lesions.

Adjuvant chemotherapy is indicated for invasive

lesions 1cm. or more in size.

Adjuvant hormonal therapy is indicated for all

hormone receptor [+] breast cancer.
 Criteria for the diagnosis of a second
primary breast cancer
1. The demonstration of a situ change in the contralateral
tumor is considered absolute proof that the contralateral
lesion is primary tumor.

2. The tumor in the second breast is considered to be a new

primary if it is histologically different from the cancer in the
first breast.

3. The carcinoma in the second breast is considered to be a

new primary if its degree of histologic differentiation is
distinctly greater that that of the lesion in the first breast.

4. In the absence of definite histologic difference, a

contralateral carcinoma is considered to be compatible with
an independent lesion provided there is no evidence of local,
regional, or distant metastases from the cancer in the
ipsilateral breast.
 TNM classification of breast cancer
 Tumor size:
– T0 no primary tumor found
– Tis in situ
– T1 =< 2 cm
 T1mic ≤ 0.1 cm (microinvasive)
 T1a > 0.1 to 0.5 cm
 T1b > 0.5 to 1 cm
 T1c > 1 to 2 cm
– T2 > 2 to 5 cm
– T3 > 5 cm
– T4 Chest wall /skin
 T4a Chest wall
 T4b Skin oedema (peau d'orange), ulceration, or
satellite skin modules
 T4c Both 4a and 4b
 T4d Inflammatory carcinoma
 Lymph nodes:
– N0 No lymph nodes
– N1 Movable axillary
– N2a Fixed axillary
– N2b Internal mammary clinically
apparent
– N3a Infraclavicular
– N3b Internal mammary clinically
apparent with axillary lymph node
involvement
– N3c Supraclavicular lymph nodes
 Distant metastasis:
– M0 No
– M1 Yes
 Stage grouping:
 Stage 0: Tis
 Stage I: T1,N0,M0
 Stage IIA: T0-1,N1,M0 or T2,N0,M0
 Stage IIB: T2,N1,M0 or T3,N0,M0
 Stage IIIA: T3,N1,M0 or T0-3,N2,M0
 Stage IIIB: T4,any N,M0
 Stage IIIC: any T,N3,M0
 Stage IV: any T,any N,M1
 Treatment and Prognosis
 Depends upon the grade and stage of the
cancer as well as the overall health of the
patient and the wishes of the patient.
 A localized carcinoma can be removed
completely with local excision (lumpectomy)
with margins free of tumor. This is termed
"breast conserving surgery" (BCS). At the
same time sampling of axillary lymph nodes
can be done to determine if lymph node
metastases are present. A total mastectomy
can be performed. The survival following BCS
is generally as good as for total mastectomy.
 Surgical procedures may be combined with
radiation therapy and or chemotherapy.
 More extensive cancers may be treated with
a modified radical mastectomy with removal
of the entire breast and axillary lymph nodes.
 Treatment
 Curative
– Stage I and II , maybe III
- BCS, MRM
- Adjuvant therapy – Radiation

Chemotherapy
Hormonal
 Palliative – Stage IV
Approximate Survival(%) of patients
with Breast Cancer by TNM stage

TNM Stage Five Years Ten Years

0 95 90
I 85 70
IIA 70 50
IIB 60 40
IIIA 55 30
IIIB 30 20
IV 5-10 2
All 65 30
Take good care of your breasts!!!

Thank You!!